EOC - Erlanger Health System

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RELATIONSHIP WITH NETWORK PROVIDERS A. Independent Contractors Network Providers are not employees, agents or representatives of the administrator. Such Providers contract with the administrator, which has agreed to pay them for rendering Covered Services to You. Network Providers are solely responsible for making all medical treatment decisions in consultation with their Memberpatients. The Employer and the administrator do not make medical treatment decisions under any circumstances. While the administrator has the authority to make benefit and eligibility determinations and interpret the terms of Your Coverage, the Employer, as the Plan Administrator as that term is defined in ERISA, has the discretionary authority to make the final determination regarding the terms of Your Coverage (“Coverage Decisions.”) Both the administrator and the Employer make Coverage Decisions based on the terms of this EOC, the ASA, the administrator’s participation agreements with Network Providers, the administrator’s internal guidelines, policies, procedures, and applicable State or Federal laws. The administrator’s participation agreements permit Network Providers to dispute the administrator’s Coverage decisions if they disagree with those decisions. If Your Network Provider does not dispute a Coverage decision, You may request reconsideration of that decision as explained in the Grievance Procedure section of this EOC. The participation agreement requires Network Providers to fully and fairly explain the administrator’s Coverage decisions to You, upon request, if You decide to request that the administrator reconsider a Coverage decision. The administrator has established various incentive arrangements to encourage Network Providers to provide Covered Services to You in an appropriate and cost effective manner. You may request information about Your Provider’s payment arrangement by contacting the administrator’s customer service department. B. Termination of Providers’ Participation The administrator or a Network Provider may end their relationship with each other at any time. A Network Provider may also limit the number of Members that he, she or it will accept as patients during the term of this Agreement. The administrator does not promise that any specific Network Provider will be available to render services while You are Covered. C. Provider Directory A Directory of Network Providers is available at no additional charge to You. You may also check to see if a Provider is in Your Plan’s Network by going online to www.bcbst.com. NOTIFICATION OF CHANGE IN STATUS Changes in Your status can affect the service under the Plan. To make sure the Plan works correctly, please notify the Employer when You change: ! name; ! address; ! telephone number; ! employment ! status of any other health coverage You have. Subscribers must notify the administrator of any eligibility or status changes for themselves or Covered Dependents, including: ! the marriage or death of a family member; ! divorce; ! adoption; ! birth of additional dependents; ! termination of employment; or ! change in student status. 2 Erlanger Health System 2009
ELIGIBILITY Any Employee of the Employer and his or her family dependents who meet the eligibility requirements of this Section will be eligible for Coverage if properly enrolled for Coverage, and upon payment of the required Payment for such Coverage. If there is any question about whether a person is eligible for Coverage, the Plan shall make final eligibility determinations. A. Subscriber To be eligible to enroll as a Subscriber, an Employee must: 1. Be a full-time Employee of the Employer, who is Actively at Work; and 2. Satisfy all eligibility requirements of the Plan; and 3. Enroll for Coverage from the Plan by submitting a completed and signed Enrollment Form to the Plan. Employees can submit an Enrollment Form in any format agreed to by the Plan and Us (i.e., electronically, faxed, paper, etc.) B. Covered Dependents To be eligible to enroll as a Covered Dependent, a Member must be listed on the Enrollment Form completed by the Subscriber, meet all dependent eligibility criteria established by the Employer, and be: 1. The Subscriber’s current spouse as recognized by the state where the Subscriber lives; or 2. The Subscriber’s or the Subscriber’s spouse’s: (1) natural child; (2) legally adopted child (including children placed for the purpose of adoption); (3) step-child(ren); or (4) children for whom the Subscriber or Subscriber’s spouse is the legal guardian; who are: a. Unmarried; is, and continues to be, both (1) incapable of self-sustaining employment by reason of mental retardation or physical handicap; and (2) chiefly dependent upon the Subscriber for economic support and maintenance, provided proof of such incapacity and dependency is furnished within 31 days of the child’s attainment of the applicable limiting age and subsequently as may be required, but not more frequently than annually. In addition, such unmarried child must be a dependent enrolled in the Plan prior to attaining the applicable limiting age. Dependents who permanently reside outside the United States are not eligible for Coverage under the EOC. The Plan’s determination of eligibility under the terms of this provision shall be conclusive. The Plan reserves the right to require proof of eligibility including, but not limited to, a certified copy of any Qualified Medical Child Support Order or certification of full-time student status. C. Waiting Period The Plan has a Waiting Period. Each Employee must wait until the first of the month following one month after he or she is hired before he or she is eligible for Coverage. D. Coverage For Retirees A Subscriber who qualifies as a Retiree may still be an eligible Employee under this EOC after leaving full time employment. A Retiree is a Subscriber who: ! Retires from full time employment with Employer; and ! Is between ages 55 and 64 at the time he or she retires. Retirees may be required to pay a portion of the Payment to the Employer. Dependents of Retirees may continue Coverage through CCOBRA after the Retiree ceases to be eligible. Check with the Employer for full details. b. Less than 24 years old; and c. dependent on the Subscriber or Subscriber’s spouse for at least 50% of his or her support; or 3. A child of Subscriber or Subscriber’s spouse for whom a Qualified Medical Child Support Order has been issued; or 4. An unmarried child of Subscriber or Subscriber’s spouse, as defined above, who 3 Erlanger Health System 2009
Page 1 and 2: ERLANGER HEALTH SYSTEM Health Benef
Page 3 and 4: Erlanger Health System 2009
Page 5: INTRODUCTION This Evidence of Healt
Page 9 and 10: EFFECTIVE DATE OF COVERAGE If You a
Page 11 and 12: SUBROGATION AND RIGHT OF REIMBURSEM
Page 13 and 14: BLUECARD/BLUECARD PPO PROGRAM When
Page 15 and 16: CLAIMS AND PAYMENT When You receive
Page 17 and 18: PRIOR AUTHORIZATION, CARE MANAGEMEN
Page 19 and 20: Your concern will be noted and inve
Page 21 and 22: the Termination of Coverage Section
Page 23 and 24: COORDINATION OF BENEFITS This EOC i
Page 25 and 26: (1) First, the Plan of the parent w
Page 27 and 28: of This Plan and such rule states t
Page 29 and 30: II. DESCRIPTION OF THE REVIEW PROCE
Page 31 and 32: DEFINITIONS Defined terms are capit
Page 33 and 34: 24. Employee - A person who fulfill
Page 35 and 36: Investigational Service. If the Med
Page 37 and 38: difference between Billed Charges a
Page 39 and 40: ATTACHMENT A: COVERED SERVICES AND
Page 41 and 42: C. Office Surgery Medically Necessa
Page 43 and 44: injections; (7) fertility drugs, (8
Page 45 and 46: The following Medically Necessary a
Page 47 and 48: d. If You receive Prior Authorizati
Page 49 and 50: d. Items to replace those that were
Page 51 and 52: 3. Three intensive outpatient progr
Page 53 and 54: syringes used in conjunction with i
Page 55 and 56: k. Maintenance Drug - Prescription
Page 57 and 58:
EVIDENCE OF COVERAGE ATTACHMENT B:
Page 59 and 60:
EVIDENCE OF COVERAGE ATTACHMENT C:
Page 61 and 62:
(Family/General Practice, Internal
Page 63 and 64:
Other Wellcare Screenings, age 6 an
Page 65 and 66:
Schedule of Pharmacy Prescription D
Page 67 and 68:
Miscellaneous Limits: In-Network Se
Page 69 and 70:
Diagnostic Services and Preventive
Page 71 and 72:
Services Received at a Facility Inp
Page 73 and 74:
Organ Transplant Services Organ Tra
Page 75 and 76:
Benefit percentages apply to BCBST
Page 77 and 78:
EVIDENCE OF COVERAGE ATTACHMENT C:
Page 79 and 80:
(Family/General Practice, Internal
Page 81 and 82:
Other Wellcare Screenings, age 6 an
Page 83 and 84:
Schedule of Pharmacy Prescription D
Page 85 and 86:
Miscellaneous Limits: In-Network Se
Page 87 and 88:
the U. S. Department of Labor, or m
Page 89 and 90:
UNIFORMED SERVICES EMPLOYMENT AND R
Page 91 and 92:
MARKETING: Your medical information
Page 93:
www.bcbst.com BENEFIT QUESTIONS? Ca
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EOC - Erlanger Health System

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